Corrective Action Plans

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Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: John Lutz jlutz@christopher-community.org Current Findings on the Schedule of Findings...
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: John Lutz jlutz@christopher-community.org Current Findings on the Schedule of Findings and Questioned Costs Finding 2024-003 The Company will work to engage its auditors to perform the December 31, 2025 audit in March of 2026 and complete the audited submission within 90 days after the end of the fiscal year. The current year audited submission will be complete and filed upon completion of this audit.
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: John Lutz jlutz@christopher-community.org Current Findings on the Schedule of Findings...
Name of auditee: St. Clare Apartments Housing Development Fund Company, Inc. TIN: 16-1524084 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: John Lutz jlutz@christopher-community.org Current Findings on the Schedule of Findings and Questioned Costs Finding 2024-002 Management understands HUD’s reserve for replacements required deposit requirements and will deposit the $58,800 as soon as cash flow allows.
Strengthen GL coding controls for disaster-related activity; • Implement a secondary review over expenditure coding; • Periodically reconcile disaster expenditures across all GL accounts to ensure completeness and proper classification in the FE MA-designated tracking account.
Strengthen GL coding controls for disaster-related activity; • Implement a secondary review over expenditure coding; • Periodically reconcile disaster expenditures across all GL accounts to ensure completeness and proper classification in the FE MA-designated tracking account.
Implement and document a timekeeping record-retention control that: * Reconciles payroll charges to system time entries for each day prior to reimbursement; * Flags missing daily time records for corrective action before costs are submitted; and * Requires a secondary review to verify documentation ...
Implement and document a timekeeping record-retention control that: * Reconciles payroll charges to system time entries for each day prior to reimbursement; * Flags missing daily time records for corrective action before costs are submitted; and * Requires a secondary review to verify documentation supports the period of performance for each charge.
Management will implement effective controls to identify federal grant moneys and ensure timely reporting.
Management will implement effective controls to identify federal grant moneys and ensure timely reporting.
Management acknowledge the auditors findings and is working with the Start Early Policy Council to incorporate the required oversight activities into the meetings.
Management acknowledge the auditors findings and is working with the Start Early Policy Council to incorporate the required oversight activities into the meetings.
Management recognizes that the payroll software transition and the absence of formally documented procedures governing payroll data preservation and time-and-effort reporting resulted in gaps in compliance. Specifically, legacy payroll and timesheet data were not fully preserved prior to system migr...
Management recognizes that the payroll software transition and the absence of formally documented procedures governing payroll data preservation and time-and-effort reporting resulted in gaps in compliance. Specifically, legacy payroll and timesheet data were not fully preserved prior to system migration, and payroll allocations were, for a period, based on budgeted estimates rather than actual time worked. Management started implementing corrective actions to address both the immediate documentation gaps and the underlying internal control weaknesses. 1. Time-and-Effort Documentation System CPA transitioned to a new standardized payroll and time-reporting system in early 2024, which requires all employees whose compensation is charged in whole or in part to federal awards to document actual time worked, as follows: o Currently employees record time by department and program activity. o In December 2025, management is configuring the payroll system to allow employee time allocations down to the individual contract level. o Time reporting will be based on actual hours worked, not budgeted or estimated percentages and replace prior budget-based allocation methodologies. o Timesheets are reviewed and approved by supervisors on a bi-weekly basis and are maintained as part of CPA’s official payroll and accounting records. Management will establish guidelines and document formal procedures to ensure full data preservation prior to any future system migrations, including payroll, HR, or financial systems. These procedures include: o A mandatory pre-migration data inventory and archival checklist, approved by Finance and IT leadership o Secure retention of legacy payroll, timesheet, and personnel records in accordance with CPA’s record-retention policy o Verification testing to confirm data completeness and accessibility before decommissioning any legacy system o Written approval by the Chief Financial Officer prior to system cutover
To address this finding and prevent future delays, CPA has implemented the following corrective actions: 1. Centralized Grant Reporting & Billing Tracker CPA has developed and implemented a centralized Master Grant Reporting and Billing Tracker to monitor all grant-related submissions. The tracker c...
To address this finding and prevent future delays, CPA has implemented the following corrective actions: 1. Centralized Grant Reporting & Billing Tracker CPA has developed and implemented a centralized Master Grant Reporting and Billing Tracker to monitor all grant-related submissions. The tracker captures, at a minimum: o Required financial, programmatic, and performance reports o Grantor and pass-through entity reporting requirements o Reporting frequency (monthly, quarterly, and annual) o Internal preparation and review deadlines o Final grantor submission due dates 2. Defined Roles and Accountability The Finance Department is responsible for maintaining the tracker and monitoring compliance with all reporting deadlines. Program Leadership is responsible for providing timely programmatic and supporting documentation to Finance in accordance with established internal deadlines. 3. Ongoing Monitoring and Oversight The Master Grant Reporting and Billing Tracker is reviewed on a regular basis by Finance and shared with Program Leadership and Executive Management to ensure visibility, accountability, and timely escalation of potential delays. 4. Preventive Controls Internal deadlines have been established in advance of external due dates to allow adequate time for review, reconciliation, and approval prior to submission. These corrective actions strengthen CPA’s internal controls over grant reporting and billing, will improve coordination between Finance and Program teams, and are expected to ensure timely submission of all required reports and billings going forward.
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully sub...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2024-007 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management ensures the tenant security deposit bank account equals the tenant deposit liability at all times. Action Taken: We agree with Finding 2024-007 and the recommendation described in the accompanying schedule of findings and questioned costs. The tenant security deposit account was funded in full by Remnant Management Inc. on October 1, 2024. The account balance equals the total tenant security deposit liability in accordance with Uniform Guidance and HUD requirements. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully sub...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2024 Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2024-006 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management ensure supporting documentation is maintained and reconciled for all cash receipts of the project. Action Taken: We agree with Finding 2024-006 and the recommendation described in the accompanying schedule of findings and questioned costs. The Corporation has executed a new management agreement with Remnant Management Inc. effective October 1, 2024. Remnant Management Inc. will provide additional oversight to ensure supporting documentation is maintained and reconciled for all cash receipts of the project beginning October 1, 2024 and going forward. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully sub...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2024-005 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management ensure that the annual financial reports to HUD are submitted by the required due dates. Action Taken: We agree with Finding 2024-005 and the recommendation described in the accompanying schedule of findings and questioned costs. The project was unable to pay the prior audit fees timely due to limited available cash flow causing a delay in the audits. Management will work to improve cash flow for timely payment of the required annual audits. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully sub...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2024-004 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management ensure that the data collection forms are submitted electronically to the FAC each fiscal year going forward. Action Taken: We agree with Finding 2024-004 and the recommendation described in the accompanying schedule of findings and questioned costs. The project was unable to pay the prior audit fees timely due to limited available cash flow causing a delay in the audits. Management will work to improve cash flow for timely payment of the required annual audits. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully sub...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2024-003 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: We recommend that management monitor the annual surplus cash and all required payments from any surplus cash. Action Taken: We agree with Finding 2024-003 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will submit a request to re-evaluate payments due based on no surplus cash available at December 31, 2020 - December 31, 2024. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully sub...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2024-002 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: We recommend that management ensure supporting documentation is maintained for all disbursements from project operations. Action Taken: We agree with Finding 2024-002 and the recommendation described in the accompanying schedule of findings and questioned costs. The Corporation has executed a new management agreement with Remnant Management Inc. effective October 1, 2024. Remnant Management Inc. will ensure supporting documentation is maintained for all disbursements from project operations beginning October 1, 2024 and going forward. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully sub...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN February 10, 2026 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2024-001 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2024-001 and the recommendation described in the accompanying schedule of findings and questioned costs. The Corporation has executed a new management agreement with Remnant Management Inc. effective October 1, 2024. Remnant Management Inc. will ensure that all transactions are properly recorded and that key accounts are reconciled and reviewed on a periodic basis beginning October 1, 2024 and going forward. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
The Corporation should establish procedures and internal controls focusing on and including document retention policies to ensure that all required client documentation is maintained.
The Corporation should establish procedures and internal controls focusing on and including document retention policies to ensure that all required client documentation is maintained.
Management should transfer funds from the operating account to fully fund the tenant security deposits account.
Management should transfer funds from the operating account to fully fund the tenant security deposits account.
The Corporation should file the June 30, 2024, financial statements as soon as possible and should ensure the annual financial report is filed within 30 days after the financial statements are available for issue and within nine months of fiscal year end.
The Corporation should file the June 30, 2024, financial statements as soon as possible and should ensure the annual financial report is filed within 30 days after the financial statements are available for issue and within nine months of fiscal year end.
The Corporation should file the June 30, 2024, financial statements as soon as possible and should ensure the annual financial report is filed within 90 days in future periods.
The Corporation should file the June 30, 2024, financial statements as soon as possible and should ensure the annual financial report is filed within 90 days in future periods.
The Corporation should establish procedures and internal controls focusing on and including document retention policies to ensure that all required client documentation is maintained.
The Corporation should establish procedures and internal controls focusing on and including document retention policies to ensure that all required client documentation is maintained.
Management should transfer funds from the operating account to fully fund the tenant security deposits account.
Management should transfer funds from the operating account to fully fund the tenant security deposits account.
The Corporation should file the June 30, 2024, financial statements as soon as possible and should ensure the annual financial report is filed within 30 days after the financial statements are available for issue and within nine months of fiscal year end.
The Corporation should file the June 30, 2024, financial statements as soon as possible and should ensure the annual financial report is filed within 30 days after the financial statements are available for issue and within nine months of fiscal year end.
The Corporation should file the June 30, 2024, financial statements as soon as possible and should ensure the annual financial report is filed within 90 days in future periods.
The Corporation should file the June 30, 2024, financial statements as soon as possible and should ensure the annual financial report is filed within 90 days in future periods.
The City will modify its internal accounting systems to ensure that the encumbrance and subsequent expenditure of Coronavirus State and Fiscal Recovery Funds cannot occur without verification of, and inclusion of supporting documentation within, the accounting system that a vendor is not suspended o...
The City will modify its internal accounting systems to ensure that the encumbrance and subsequent expenditure of Coronavirus State and Fiscal Recovery Funds cannot occur without verification of, and inclusion of supporting documentation within, the accounting system that a vendor is not suspended or disbarred or otherwise excluded from receiving these funds. The City will also implement additional detailed senior management review of proposed encumbrance and expenditures for these funds to verify that SAM compliance checks have occurred.
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule...
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.
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